Joined up care is needed to address multimorbidity
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2023)

Medicine is inherently siloed: clinical guidelines, medical education, and research tend to focus on single conditions. But this stratification of specialities is artefactual and reductionist. In practice, multimorbidity—that is, two or more long-term health conditions in a single individual—can arise from the same cause, one condition can increase the risk of another, or the side effects of one treatment can trigger a completely different disease, necessitating multidisciplinary collaboration and decision making. For instance, smoking increases the risk of peripheral vascular disease (increasing the risk of subsequent, other cardiovascular disease) and lung cancer (the treatment of which with radiotherapy or chemotherapy can cause infertility). One disease can thus initiate a cascade into several. Multimorbidity is common: a 2023 study in eClinicalMedicine found a global prevalence of multimorbidity of 37·2% (95% CI 34·9–39·4). Despite this ubiquity, most health systems still treat one disease at a time, and the ability to prevent, diagnose, and manage one disease does not necessarily predict success in controlling other diseases, even in the same population. In this issue, Urisha Singh and colleagues analyse the health needs of 9898 people living with one or more of HIV, hypertension, and diabetes in South Africa. Half of this population had at least one unmet health need (ie, for treatment optimisation, engagement in care, or a diagnosis). Those with HIV predominantly had well controlled disease: only 21·7% had unmet HIV-related health needs. However, this finding contrasts with troubling results in those with diabetes (93·1% with unmet needs) and with hypertension (58·2%). There was substantial geospatial overlap between populations without diagnosis or optimal control of HIV and of non-communicable diseases (NCDs). As such, the authors recommend integrated services for diagnosis and management of infectious diseases and NCDs. Initiatives to address infectious diseases regularly show the logistical benefits and cost-effectiveness of integrated programmes. For instance, vaccines for different diseases are often combined in a single injection, to minimise the number of clinical visits needed and thus increase the likelihood of timely protection. Similarly, combination antiparasitic drugs are used in mass drug administrations to control several neglected tropical diseases that often co-occur, such as lymphatic filariasis and scabies. However, equivalent programmes targeting multimorbidity are less common, particularly those addressing NCDs. With coming epidemiological transitions, more NCDs are expected in low-income and middle-income countries, with concomitant increases in multimorbidity. How can we best understand and address multimorbidity? First, specialists must understand the diseases that cluster around their specialty. When assessing risk of disease, research and practice mostly focus on modifiable risk factors, like smoking and malnutrition, and on associations between a disease of study and cardiometabolic risk factors, like obesity. However, bioinformatic approaches have revealed a rich but underexplored network of symptoms and diseases that co-occur more frequently than would appear by chance. For instance, polycystic ovarian syndrome is seen alongside unexpected diseases, such as asthma. Clinicians should know prevalent comorbidities of a disease when making treatment decisions, to avoid exacerbating (or even improve) seemingly unrelated symptoms. Regrettably, patients with multimorbidity are often excluded from trials because of the additional complexity of their inclusion for study interpretation, so treatment outcomes in people with comorbid conditions are poorly understood, particularly among people of different ages, sexes, or ethnicities. As such, trial sample populations should always include those with common comorbid conditions, without which we cannot be confident how safe nor effective treatments are in a clinically significant proportion of the real-world patient population. Finally, we need to redesign health systems with an expectation of multimorbidity and to track an individual's lifelong risks and how these risks interact. For instance, pre-eclampsia during pregnancy doubles a person's risk of future coronary heart disease, stroke, and death from a cardiovascular cause. However, this history is unlikely to be considered when prescribing routine medications after pregnancy that increase cardiovascular risks, potentially putting these patients in danger. All patients deserve safe, individualised care, across specialties and across their life course. Although more complex, joined up care will be necessary to achieve this goal. The impact of ivermectin, diethylcarbamazine citrate, and albendazole mass drug administration on the prevalence of scabies and soil-transmitted helminths in school-aged children in three municipalities in Timor-Leste: a before–after assessmentIvermectin, diethylcarbamazine citrate, and albendazole MDA was associated with substantial reductions in prevalence of scabies, impetigo, and T trichiura, and of moderate-to-heavy intensity A lumbricoides infections. Combination MDA could be used to support integrated control programmes to target multiple NTDs. Full-Text PDF Open AccessBurden of non-communicable diseases in sub-Saharan Africa, 1990–2017: results from the Global Burden of Disease Study 2017NCDs in sub-Saharan Africa are posing an increasing challenge for health systems, which have to date largely focused on tackling infectious diseases and maternal, neonatal, and child deaths. To effectively address these changing needs, countries in sub-Saharan Africa require detailed epidemiological data on NCDs. Full-Text PDF Open AccessThe met and unmet health needs for HIV, hypertension, and diabetes in rural KwaZulu-Natal, South Africa: analysis of a cross-sectional multimorbidity surveyAlthough people living with HIV predominantly have a well controlled condition, there is a high burden of unmet health needs for people living with hypertension and diabetes. In South Africa, adapting current, widely available HIV care services to integrate non-communicable disease care is of high priority. Full-Text PDF Open Access